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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT 'CALL 209 95x{3--7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 Sy 2 �J EC 'i 1 P K17 CITY)LP/ \ e�in S :2 l 0 An <br /> D <br /> CROSS STREET ' \\ PARCEL SIZE LANG USE APPLICATION#-'') J m <br /> OWNER NAME -1'-G '�� liD�)L5' kmelfssgHONE,'S-. � •.'( �5�7 "• I Aeon)P4�( <br /> OWNER ADDRESS li C 7 /d tb�✓I ,�� RY'TATEILP 00 ,E/1 AC� <br /> [ `2779 <br /> CONTRACTOR �[,tyl }�1 O� PHONE J�-/C� �2 /-7�j <br /> ('-I { <br /> CONTRACTOR ADDRESS S X 1 CRY/STATFJLP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYOISTATEILP <br /> /` •-� nn <br /> LICENSE j/,C-57 C-61 D-09 _Other NUMBER 29�5 EXPIRATioN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ,ZCDomesticJPrivate Irrigation/Agricultural =:Industrial Water Quality Monitoring --Soil Sampling/Characterization <br /> Public Water System <br /> H dflerent from Owner. water system me Name or acro um r <br /> TYPE OF WORN New Well _.Replacement Well r Well AlteralionlModification 'Other <br /> Monitoring Well(s) #of wells Soil Boring(s) f of borings Geotechnical eorcorirgs <br /> Out-0f-Service Well Out-OfService Well Renewal .Cross-Connection Repair <br /> New Pump Pump Replacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method),C Mud Rotary 'Air Rotary Auger "" Cable Tool - Push Point Other <br /> Proposed Well DepthF7:212 nft Excavation 1 ,Y1 in diameter - Open Bottom YGravel Pack/Gravel Size 1)4 -_in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_L� in Thickness/Gauge/ASTM Schad 1 7 i Steel X-,Plastic Stainless Steel __Other <br /> Grout Seal Depth a';('- ft Neat Cement(941b bagi5-10 ga)water) �r Sand Cement sack mixn gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method)Pumped Free Fall Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller _:Pump Contractor Other <br /> Concrete Pedestal-Dimensions:Width_j.� ft Length ft Thick in -Christy Box Stove Pipe <br /> PUMP Submersible-Turbine -Other HP c- Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI ,X224 HOUR <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED v__� % CII�rC+ TITLE C i C S 1 C Y 1 DATE <br /> r <br /> S <br /> y�t�ell PAYF <br /> �.--I- f I I I I — R�cv�o <br /> N r?62017 <br /> 4 I!NV/ROti,- CO68,rU <br /> t' WFtiT <br /> l <br /> ILA <br /> DEPARTMENT USE ONLY LJ <br /> Application Accepted Bi6L�—y Date I U,.1 I Are. r / Employee ID# Un Cf <br /> Grout Inspection By Dale 7 SPECIAL Well POrMit J <br /> Pump Inspection By Date j l 11. i 1 7 WAIVER Received?�T <br /> Soil Boring Inspection By Date -^'�y t t Constructed Well Depth J r-t/ It <br /> N A•" - I' L U l Y / L r "X J c+H1 <br /> ME <br /> cau <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WeIIID# VJ 6C <br /> Codes Info B Cash Remitted Service Re uest# y'� djq <br /> �13GG Inc 3r13 ' PAD >Je Pty <br /> }r1I '. 3��1�, "[0 Bucy, <br /> EMD 43-06 WELL/PUMP PERMIT <br /> 4rwnz <br /> y55o o s 3 /�/r7 I,LI PM37528 effW 2-7T <br />